Background

Genital reconstructive surgery is a specialized field of surgical medical which deals with reconstruction of genital organ systems or alteration of genital organs. It offers functional and reconstructive goals, corrective and aesthetic objectives and gender affirmation purposes. It focuses on congenital malformations; trauma; developmental abnormalities; or abnormalities resulting from neoplastic diseases, infections, or other diseases.

Indications

Congenital Anomalies

Hypospadias and Epispadias: This condition are characterized by an abnormal location of the urethral opening.

Ambiguous Genitalia (Disorders of Sex Development): Such diseases as congenital adrenal hyperplasia or androgen resistance syndrome.

Micropenis or Clitoromegaly: Significant size abnormalities requiring correction.

 Acquired Conditions Trauma: Genital body shattering from mishaps, burns, or attacks to tissues themselves.

 Cancer: Reconstruction after the tumours affecting genital area- the penis, vulva or testes have been excised through surgery (like penile, vulvar or testicular carcinoma).

Functional Disorders

Urinary or Sexual Dysfunction: Reconstructive surgery for bringing back the functionality due to developmental problems, injury or other reasons.

Urethral Stricture Disease: Stricture disease of the urethra requiring urethroplasty.

Psychological Problems

Body Dysmorphic Disorder or extreme mental disturbance associated with genitalia.

Labiaplasty: Surgery that makes the lips of the female genitalia smaller or change their shape for the purpose of beautification or functional reasons.

Contraindications

Severe Medical Conditions:

Uncontrolled cardiovascular, pulmonary or renal diseases.

Febrile illnesses (e.g. HIV or hepatitis):

Blood coagulopathies, or conditions that have not been corrected that cause bleeding.

Lack of Gender Dysphoria Diagnosis: For gender-affirming procedures, lack of appropriate screening and unlikely recommendation from a skilled mental health care expert in compliance with WPATH guidelines.

Non-Adherence to Preoperative Requirements: Lack of compliance with hormonal therapy requirements (if any for tissue changes in the gender-affirming surgery).

Preoperative mis-assessment of fitness for surgery.

History of Pelvic or Abdominal Surgery or Radiation: Changes or risk may be imposed depending on the presence of scar tissue or had poor blood circulation at the site of operation.

Hormonal Therapy Contraindications: In cases where preoperative hormonal therapy is contraindicated (e.g., history of hormone-sensitive cancers or thrombosis), surgeons may need alternative approaches.

Outcomes

Equipment

Scalpels and Blades

Hemostats

Forceps

Scissors

Metzenbaum scissors

Mayo scissors

Needle Holders

Suction Equipment

Vascular Clamps

Electrocautery Devices

Tissue Retractors

Loupes or Microscope

Penile Implant Kits

Flap Reconstruction Tools

Surgical Mesh

Patient Preparation

Patient preparation before surgery

Medical Evaluation

Comprehensive Health Assessment: Evaluate overall health, including cardiovascular, pulmonary, and metabolic status.

Laboratory Tests: A complete blood count (CBC), electrolyte level, coagulation factors, HIV/ hepatitis B and C, liver function tests.

Smoking and Substance Use: Smoking and substance use should be discouraged at least three to four weeks before surgery to improve wound healing and decrease chances of complications.

Nutrition: Address any nutritional deficiencies to aid the healing process.

Pelvic Health and Function For vaginoplasty: They might need to undergo bowel preparation, and the patient may be instructed on dilation practices.

For phalloplasty: The location of the donor site especially the forearm or thigh should be evaluated for compatibility.

Physical Preparation:

Ensure skin health in the surgical area and donor site.

Laser hair removal or electrolysis may be required on the surgical or donor site well in advance.

Patient Positioning:

Supine Position

Common for penile reconstruction, urethral surgery, or vaginoplasty.

Lithotomy Position

Often used for surgeries involving the perineum, vaginal canal, or urethra.

Male-to-Female Genital Reconstructive Surgery (Vaginoplasty)

Step 1-Preoperative Assessment and Preparation:

Consultation: Detailed discussion of the procedure, desired outcomes, potential risks, and postoperative care.

Preoperative Testing: Blood tests, imaging, and psychological evaluation (especially for gender-affirming surgery).

Anesthesia: General anesthesia is commonly used for vaginoplasty.

Step 2-Marking and Positioning:

The patient is positioned in the lithotomy position (lying on the back with the legs elevated and spread apart).

Surgical markings are made to guide the incision, such as the planned vaginal opening, clitoral hood, and labia majora.

Step 3-Incision and Urethral Mobilization:

Penile Skin Flap Creation: The surgeon typically makes an incision around the penis to preserve the penile skin (often used to create the vaginal lining).

Urethral Preservation: The urethra is carefully dissected and isolated. In gender-affirming surgery, it may be shortened to avoid a long, visible urethra in the neo-vagina.

Step 4-Removal of Male Genital Structures (if applicable):

Penectomy: The shaft of the penis is removed (with careful preservation of skin for the neo-vagina).

Scrotal Skin: If used for the construction of the vaginal lining, the scrotal skin is harvested. In some cases, scrotal tissue can also be used for labial construction.

Step 5-Creation of the Vaginal Cavity:

Vaginal Canal Formation: A tunnel is created between the urethra and rectum to form the vaginal canal. The depth of the vagina is determined based on the patient’s anatomy.

Vaginal Lining: The skin from the penis or scrotum is used to line the newly created vaginal canal. It is rolled and sutured into place.

Nerve Preservation: Care is taken to preserve nerves for sexual function, particularly when constructing the neo-clitoris from the glans of the penis.

Step 6-Clitoral Construction:

Clitoral Hood Creation: The glans of the penis (if available) is preserved to form a sensitive neo-clitoris.

Nerve Anastomosis: The nerves are reattached to the glans to maintain sensation.

Step 7-Labial Construction:

Labia Majora: The skin from the scrotum is used to create the labia majora, the outer folds of the vulva.

Labia Minora: If needed, additional tissue may be used or created from the remaining skin to form the labia minora, the inner folds of the vulva.

Step 8-Closure and Final Shaping:

The surgical site is carefully sutured, ensuring the neo-vulva has a natural appearance and that the vaginal canal remains patent.

Hemostasis is ensured, bleeding is controlled, and the surgical site is closed.

Step 9-Postoperative Care:

Drains: Temporary drains may be placed to reduce fluid accumulation at the surgical site.

Dilation: After surgery, vaginal dilation is critical for maintaining the size and depth of the newly created vaginal canal. The patient will be instructed on the frequency and technique for dilation, often for several months.

Antibiotics and Pain Management: Postoperative pain management and infection prevention are essential.

Step 10-Follow-up and Long-Term Care:

Regular Check-ups: Follow-up visits are important to monitor healing and ensure the vagina is maintaining its shape and size.

Psychosocial Support: Ongoing psychological support may be necessary to help with emotional and physical recovery.

Complications

Infection:

Skin or soft tissue infections at the surgical site.

Deep infections, such as abscesses or osteomyelitis in severe cases.

Urinary tract infections (UTIs), particularly in procedures involving the urethra.

Bleeding and Hematoma:

Postoperative bleeding may require reoperation.

Hematomas can cause pain and may need drainage.

Wound Healing Problems:

Dehiscence (wound reopening).

Necrosis of skin or tissue due to poor blood supply.

Scarring:

Unsightly or hypertrophic scars.

Phalloplasty (construction or reconstruction of the penis)

Flap-Related Issues:

Partial or total flap loss.

Poor graft integration.

Urethral Complications:

Urethral strictures (narrowing of the urethra causing obstruction).

Fistulas (abnormal connections between the urethra and the skin).

Implant Complications (if penile prosthesis is inserted):

Device malfunction or infection.

Extrusion of the implant through the skin.

Cosmetic Concerns:

Asymmetry or dissatisfaction with the penile appearance.

Vaginoplasty (construction or reconstruction of the vagina)

Vaginal Stenosis:

Narrowing of the vaginal canal, making penetration difficult.

References

https://pubmed.ncbi.nlm.nih.gov/32061539/

References

https://pubmed.ncbi.nlm.nih.gov/32061539/